HomeMy WebLinkAboutApplication and WC __ _ , . _._ ._ _.-.
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; � TOWN OF YARMOUTH BOARD OF HEALTH � � ;
� �� � APPLICATION FOR LICENSE/PERMIT „ 16 � :��� �' � ���� � � ����e'�
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�'°" * Please complete form and attach all necessary�dc��um��s`_ ece ber 1 S 201 S
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` Failure to do so will result in the return f oury� l��ation� a;ket.� _ _�_ �
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E�TABLISHMENT NAME: 7- CLCY�fv rc%t�^�� 5���� TAX ID: �`� `
LOCATION ADDRESS: �}�-I�.1 J')11�l!4' .�1�'• �1��T YH-r�r�)�3�'T� TEL.#:(�L�.4,�y7?��1 ���I
MAILING ADDRESS:�4� l�1�F�h`��'= k'C:L� d�t;�T�A-�,r1)�z��i H , M/� 02.�73
E-MAIL ADDRESS:
OWNER NAME: /YIU/9T51M CH-�}ll�if'/�y
CORPORATION NAME (IF APPLICABLE):
NTANAGER'S NAME: /nU/3'T.�lNI L�ff'At�`J1f14Y � M CH'�D TEL.#:� K�c3b7-d Z/
MAILING ADDRESS:l�9T/W��fT�,��vTft ��_��'�.��/�jQUTN iYl� o2G7;
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Paol Operator(s) and attach a copy of the certification to this form.
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Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
years' records. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
L 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. _ _ _ _ 2. _ --
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as'defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1.' 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich '
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2,
3. 4,
RESTAURANT SEATING: TOTAL# '
.__—. �_ -8��1f;�--�}��-(31�T�.,"
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LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
_INN $55 CAMP $55 SWIMMING POOL$I l0ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSB REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE' PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 ��
�<25,000sq.ft. $150 �(o =FROZENDESSERT $40 ( TOBACCO $110
NAMECHANGE: $is AMOUNTDUE _ $ 2,�o.0O
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION ;� �
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Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ;
CERT. OF INSURANCE ATTACHED��
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
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Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of�our permits. PLEASE CHECK �
APPROPRIATELY IF PAID:
YES ✓ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
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TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be '
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. �
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not mare than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy �
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. �
POOLS �
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POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected �
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) '
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been i
inspected and opened. i
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POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing. �
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FOOD SERVICE i
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contac�the
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtamed at the Health Department,or from the Town's website at www;varmouth.ma.us under Health Deparhnent,
Downloadable Forms. �
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen j
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. ,
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: �l"1� ''�� SIGNATURE:
* � /
PRINT NAME & TITLE: ��YI Uf1'�l M CIfJ�'(J O�`/ (qOW���
Rev.10/O1/15
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� The Commonwealfh of Massachusetts
' _ Department of Ind►�rstr�ial Accidents
� Office of Investigations
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' ' 1 Congress Street, Suite 1 DO '
_ Boston,MA 02I14-2017.
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv �
Business/OrganizationName: 7- �GEY�-�N �Uv� s77��'� '
Address: �'�� /Y��}/N v��Q�'ET' 12-T• Z�f'
City/State/Zip:(�t�C�ST 0 UT� /i'1�" Phone#: $��—?�7�'-'�i 1/�l
Are you an employer? Check the appropriate boz: Business Type(required):
1.�I am a employer with � employees(full and/ 5. [�Retail
or part-time).* 6. ❑RestaurantlBar/Eating Establishment
�,_ . . ' —a.nd�r�.ve iro —- - --- — -
p 7. Office and/or Sa1es(incl.real esta.te,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing '
no employees. [No workers' comp. insurance required]* 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ,
**If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: /�/���d'1 �(�l'r11T0�'YI D `N5UJ2�'1'JVG(7 COMP�N'� O� �'�'lG��G�
Insurer's Address: (iITI PLA'G& G�N�E� �A°ST oZ7/� N• �'hSI��GL f�'V� 5TC' �Oa L•B� �r' :
City/State/Zip: �f}LLI�}S 7'X 7 5'Z0� —2q J�
Policy#or Self-ins. Lic. # i.t�G 1� �,SZs�('D?� Expiration Date: ��" D l-ZO�(p
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
- --�`ine up�o$1;S�iQ:Q�"an�one-year imprisorunen�as-wetT as c�vi�pe—ina.tie�irit�ie orm o 8RI3�R ar�d�.�ine ,
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of '
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
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Si�ature: . � / Date: N� �� • �S
Phone#: ��, �Z�'"�'�'�I �
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one): ,
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other '
Contact Person: Phone#:
wwwmass.gov/dia
�1
I POLICY NIMABER WCP8525402 STANDARD WOPo(ERS COMPENSATION
� m, AND EMPLOYERS LIABILITY POLICY
�
� Mitsui Sumitomo Insurance Group wc o0 00 o�a
a POLICY NO -WCP8525402
INFORMATION PAGE -STANDARD
POLICY-RENEWAL NCCI COMPANY NO. 19089
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� wcpasas4oa oi-oi-zois oi-oi-aoi6 x�,�rr�wr,i, oa: MITSUI SUMITOMO INSURANCE oo3osoo
� wcPssas4oa COMPANY OF AMERICA
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1.MUATSIM CHAUDHRY AON RISK SRVC SW/FRNCHS 7-11
DBA: 7-ELEVEN NO. : 2464-25933D CITYPLACE CENTER EAST
444 MAIN STREET 277.1 N. HASKELL AVE. , STE 800 L.B.8
WEST YARMOUTH MA 02673 • DALLAS TX 75204-2999
FEIN # _ __ __�___
Localions—All usua�work placed oi the insured at or from which operations covered by this policy are conducted or located at the above address unless otherwise staied herein:
SEE EXTENSION OF INFORMATION PAGE
ENTITY OF INSUF�D - INDIVIDUAL
2. THE POLICY PERIOD IS FROM Ol-01-2015 TO Ol-01-2016 12:01 AM STANDAF� TIME AT THE INSUF�ED'S
MAILING ADDF�SS.
3A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO THE WORKERS COMPENSATION
LAW OF THE STATES LISTED HERE:
MA
3B. EMPLOYERS LIABILITY INSURANCE: PART TWO OF THE POLICY APPLIES TO WO�C IN EACH STATE LISTED IN ITEM
3A. THE LIMITS OF OUR LIABILITY UNDER PART TWO AF�:
I BODILY INJURY BY ACCIDENT $ 500, 000 EACH ACCIDENT
BODILY INJURY BY DISEASE $ 500, 000 EACH EMPLOYEE
BODfLY INJURY BY DISEASE $ 500, 000 POLICY LIMIT
3C. OTHER STATES INSURANCE: PART 3 OF THE POLICY APPLIES TO THE STATES, IF ANY LISTED HERE: ALL STATES
EXCEPT STATES LISTED IN 3A AND ND OH WA WY
I . .
3D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:
SEE EXTENSION OF INFQF3MATION PAGE.
4. THE PREMIUM FORTHIS POLICY WILL BE DETERMINED BY OUR MANUALS OF F�1LES, CLASSIFICATIONS, RATES AND
RATING PLANS. ALL INFOF�fVIATION REQUIRED BELOW IS SUBJECTTO VEPoFICATION AND CHANGE BY AUDIT.
PREM BASIS RATE EST
ST LOC CODE CLASSIFICATION DESCPoPTION TOTAL EST PER$100 ANNUAL
ANNUAL REMUN REMUN PREMIUM
SEE EXTENSION OF INFORMATION PAGE $ 2, 327
PREMIUM DISCOUNT: $
MINIMUM PREMIUM $ 234 EXPENSE CONSTANT: $ 338
DIVIDEND PLAN(S): TOTAL ESTIMATED CHARGE: $ 2, 842
ASSESSMENTS& TAXES: $ 133 DEPOSIT PF�EMIUM: $ 2, 842
BILLING INFORMATION WILL FOLLOW ��' -� ��� �
PI�EMIUM ADJUSTMENT SHALL BE MADE ANNUALLY. �r :��h' �.��` �y��,k..fi_.- ,
COUNTERSIGNED THIS DAY OF ,19 � " ��
ISSUE DATE 12-2 3-14
ISSUING OFFICE: LOS ANGELES AUTHORIZED REPRESENTATIVE
COPYRIGHT 1987, NATIONAL COUNC�ONCOMPENSATION INSURANCE WC 99 OA(1-97)
_ �NSURED COPY